Characteristics of electroencephalogram changes and correlation with seizures in hospitalised patients.

INTRODUCTION: Electroencephalogram (EEG) is an important investigational tool that is widely used in the hospital settings for numerous indications. The aim was to determine factors associated with abnormal EEG and its clinical correlations in hospitalised patients. MATERIALS AND METHODS: Patients with at least one EEG recording were recruited. The EEG and clinical data were collated. RESULTS: Two hundred and fifty patients underwent EEG and 154 (61.6%) were found to have abnormal EEG. The abnormal changes consist of theta activity (79,31.6%), delta activity (20, 8%), focal discharges (41,16.4%) and generalised discharges (14, 5.6%). Older patients had 3.481 higher risk for EEG abnormalities, p=0.001. Patients who had focal seizures had 2.240 higher risk of having EEG abnormalities, p<0.001. Low protein level was a risk for EEG abnormalities, p=0.003. CONCLUSION: This study emphasised that an abnormal EEG remains a useful tool in determining the likelihood for seizures in a hospital setting. The risk factors for EEG abnormality in hospitalised patients were age, focal seizures and low protein level. The EEG may have an important role as part of the workup in hospitalised patients to aid the clinician to tailor their management in a holistic manner.

Which one predicts mortality better? Hemogram and ST elevation myocardial infarction.

OBJECTIVE: The aim of this study was to determine the effectiveness of hematological parameters measured at the moment of admission to the emergency room in predicting in-hospital mortality and to determine cut-off values of strongly predictive values. SUBJECTS AND METHODS: The study began with approval of the ethics committee. In total, 1,929 patients over 18 years of age, whose date could be obtained, were included in the study. From the hemogram parameters, white blood cells (WBC), red cell distribution width, mean platelet volume, and ratio of neutrophils to lymphocytes (NLR) values were determined and recorded. CK-MB and high-sensitive Troponin T values were recorded as cardiac markers. For statistical analysis, "SPSS for Windows Version 21" package program was used. FINDINGS: About 71.7% (n = 1384) of the patients were male and 28.3% (n = 545) of the patients were female. About 92.5% of the patients (n = 1785) were discharged from the hospital, whereas the remaining 144 patients (7.5%) were exitus in the hospital. When the efficacy of hematological parameters and cardiac markers in predicting mortality was examined by receiver operating charecteristics analysis, NLR was found to be the strongest predictor (area under the curve [AUC], 0.772, standard deviation [SD] = 0.022, 95% confidence interval [CI]). It was found that the WBC value came in second place after NLR as a strong predictor of mortality (AUC, 0.749, SD = 0.024, % 95 CI). CONCLUSION: The use of predictors for the prediction of mortality for ST elevation myocardial infarction patients is of great importance for faster implementation of treatment modalities. We found that WBC and especially NLR values obtained with a simple method can be used as powerful predictors.

The relationship between blood lactate, carboxy-hemoglobin and clinical status in CO poisoning.

AIM: We aimed to determine the relationship between blood lactate, carboxy-hemoglobin (COHb) levels and the severity of clinical findings in patients with CO poisoning. PATIENTS AND METHODS: Patients over 18 years old and of both gender who were admitted to Emergency Department with the diagnosis of CO poisoning between 10.02.2008 and 17.03.2011 were enrolled in this study. Detailed physical examination of each patient was performed, patients and their relatives were informed about the study and written consents were noted. The levels of consciousness, physical examination findings, electrocardiographic findings, Glasgow Coma Scale (GCS) scores, laboratory results (lactate, COHb, CK-MB, Troponin-I levels) and applied treatments [normobaric oxygen therapy (NBOT), hyperbaric oxygen therapy (HBOT)] were recorded to standart data entry form for each patient. "SPSS for Windows version 18" package program was used for statistical analysis of the data. RESULTS: Total 201 patients were included in this study. Thirty five patients (17.4%) received HBOT and lactate; COHb, CKMB, Troponin-I levels of this group were higher than the other patients. Lactate and COHb levels were statistically significantly higher in patients with GCS < 15 than the ones with GCS = 15 (p < 0.01). The patients whose both Troponin-I and CK-MB levels increased have higher lactate levels (p = 0.038), but COHb levels of these patients did not change (p = 0.495). CONCLUSIONS: According to our study, blood lactate and COHb levels were both correlated with the changes of consciousness in CO poisoning. Blood lactate levels together with COHb in defining indications for HBO treatment might be suggested.

Acute-phase reactants and cytokines in ischemic stroke: do they have any relationship with short-term mortality?

BACKGROUND: Many unknown risk factors play a role in the etiopathogenesis of stroke. The appearance of inflammatory cells within the damaged tissue after cerebral ischemia suggests that an inflammatory response may play a role in stroke pathogenesis. In our study, we examined whether an association exists between the acute-phase reactants and the levels of cytokines, the volume and diameter of the stroke, and short-term mortality in patients who were diagnosed as acute ischemic a stroke after admission to the Emergency Department. PATIENTS AND METHODS: A total of 50 consecutive patients who applied to the Emergency Service with acute ischemic stroke were enrolled in the study. Their stroke volume were calculated and serum samples were obtained as soon as they arrived into the Emergency Service. The patients were evaluated according to the Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS). RESULTS: There was no significant correlations between stroke volume and levels of cytokine and acute-phase reactants in dead patient group or in living patient group. A correlation and statistical significance was found between stroke volume and hospital stay time in living patient group. In addition, GCS and NIHSS scores were correlated with stroke volume and was found a significant statistically. CONCLUSIONS: Scales such as GKS and NIHHS, which evaluate the functional state of patients, are the best indicators for defining prognosis in our daily practices. In addition, we found a positive correlation between levels of CRP (C reactive protein) and prognosis. However, we did not observe a statistically significant correlation between prognosis and other acute-phase reactants such as TNF-alpha, IL-6, IL-8, IL-10, fibrinogen, and leukocytes.

Identification and characterization of citrus yellow vein clearing virus, a putative new member of the genus Mandarivirus.

Molecular features and genomic organization were determined for Citrus yellow vein clearing virus (CYVCV), the putative viral causal agent of yellow vein clearing disease of lemon trees, reported in Pakistan, India, and more recently in Turkey and China. CYVCV isolate Y1 from Adana, Turkey, was used for deep sequencing analysis of the virus-induced small RNA fractions and for mechanical and graft inoculation of herbaceous and citrus indicator plants. A polyclonal antiserum was developed from CYVCV-Y1 purified from Phaseolus vulgaris and used in western blot assays to characterize the coat protein of CYVCV-Y1 and determine its serological relationship with related viruses. Contigs assembled from the Illumina sequenced short reads were used to construct the whole genome of Citrus yellow vein clearing virus (CYVCV), consisting in a positive-sense RNA of 7,529 nucleotides and containing six predicted open reading frames. The CYVCV genome organization and size resembled that of flexiviruses, and search for sequence homologies revealed that Indian citrus ringspot virus (ICRSV) (Mandarivirus, Alphaflexiviridae) is the most closely related virus. However, CYVCV had an overall nucleotide sequence identity of ≈74% with ICRSV. Although the two viruses were similar with regard to genome organization, viral particles, and herbaceous host range, CYVCV caused different symptoms in citrus and was serologically distinct from ICRSV. Primer pairs were designed and used to detect the virus by conventional and quantitative reverse transcription-polymerase chain reaction on yellow vein clearing symptomatic field trees as well as graft- and mechanically inoculated host plants. Collectively, these data suggest that CYVCV is the causal agent of yellow vein clearing disease and represents a new species in the genus Mandarivirus.

Plasma homocysteine level and 677C-->T mutation on the MTHFR gene in patients with venous thromboembolism.

BACKGROUND: The aim of this study was to evaluate the role of plasma total homocysteine level and 677C-->T mutation on the methylenetetrahydrofolate reductase (MTHFR) gene in the development of venous thromboembolism. METHODS: Thirty-six (18 male, 18 female and mean+SD; 48.3 +/- 15.5 years) patients with venous thromboembolism and 25 healthy adults (13 male, 12 female and mean +/- SD; 46.8 +/- 9.2 years) were included in the study. Fasting plasma total homocysteine level was determined by a high performance liquid chromatography. 677C-->T mutation on the MTHFR gene in peripheral blood was detected by Real Time-PCR method. RESULTS: The level of plasma total homocysteine (18.5 +/- 10.6 micromol/L) was significantly higher in patients with venous thromboembolism than in the control group (11.0 +/- 4.7 micromol/L) (p=0.015). 677C-->T mutation on the MTHFR gene heterozygosity was higher in the patient group than in the control group [13 (36.1%) and 2 (8%) respectively] but this difference was not significant (p=0.07). CONCLUSION: It is thought that a high plasma total homocysteine may cause venous thromboembolism (Tab. 2, Ref. 21). Full Text (Free, PDF) www.bmj.sk.

Unusual presentations of scorpion envenomation.

Scorpions are nocturnal arthropods that inject their venom through the victims' skin by stingers. By the envenomation, clinical manifestations in a wide spectrum may occur, including pain at one side and death because of severe cardiopulmonary or neurological abnormalities. Sometimes the victim cannot describe the insect or does not remember even being stung after the event. We present two cases of scorpion envenomation with different and rare clinical situations with a short review of the literature.

Does the expired-air carbon monoxide level reflect the severity of inflammation in COPD?

OBJECTIVES: The aim of this study is to evaluate the expired-air carbon monoxide level which relates to the severity of inflammation in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Cross sectional study. SETTING: Cukurova University, Faculty of Medicine, Department of Chest Disease, Out-patient clinic. PATIENTS: The characteristics of patients enrolled in this study were following; 20 ex-smokers with stable COPD (mean age: 68.8 +/- 7.2 years, FEV1: 45.6 +/- 16.6% of predicted), 22 current smokers with stable COPD (mean age: 58.7 +/- 8.2 years, FEVI: 57.5 +/- 20.9% of predicted), 20 healthy smokers (mean age: 55.916.0 years, FEVI: 86.7 +/- 14.2% of predicted), and 20 healthy non-smokers (mean age: 60.8 +/- 9.2 years, FEV1: 95.3 +/- 13.5% of predicted). INTERVENTION: CO level was measured in expired-air. MEAAUREMENT AND RESULTS: The measurement of expired-air CO level was measured by DisCOver, carbon monoxide analyser. It is known that the level of expired-air carbon monoxide in healthy smokers (11.8 +/- 6.4 ppm) and in current smokers with COPD (11.1 +/- 7.4 ppm) is higher than in healthy non-smokers (1.7:0.7 ppm) and in ex-smokers with COPD (2.0 +/- 1.8 ppm) (p = 0.0001). CONCLUSION: We assumed that the level of expired-air carbon monoxide may not useful in assessing the severity of inflammation in COPD (Tab. 1, Fig. 2, Ref. 23).

Ruptured hydatid cyst following minimal trauma and few signs on presentation.

Hydatid disease is a parasitic infection caused by Echinococcus granulosus characterised by cyst formation in any organ, although the liver is the most commonly involved. Hydatid cysts can rupture either spontaneously or following trauma. Surgical treatment can be life-saving. This paper reports the atypical presentation of a young girl admitted to the emergency department. She presented with pain on her palms due to falling down a few steps. Because of the rebound tenderness on the right upper quadrant of her abdomen on physical examination, bedside ultrasonography was performed to identify the underlying cause, and promptly revealed a 62 x 72 mm lobular cyst on the right lobe of the liver with free fluid in the subcapsular area. Shortly afterwards, urticaria developed. Fluid resuscitation, methylprednisolone and diphenylhydramine were administered intravenously. Afterwards she was taken to the operation room for unroofing, drainage and capitonage. In conclusion, primary care and emergency physicians should perform a complete physical examination on all admitted patients with vague symptoms and a high index of suspicion for a ruptured hydatid cyst, even following trivial trauma, especially in endemic regions.

An investigation of the anger levels of residents: medical compared with surgical disciplines.

OBJECTIVE: To evaluate medical and surgical residents' anger levels with regard to the department in which they worked, seniority, sex, satisfaction with their work environment, and the number of nightshifts worked per month. The specific situations and persons at whom residents reacted with anger were also investigated. METHODS: 116 randomly selected residents staffed in a university hospital (62 medical and 54 surgical residents) were enrolled. The trait anger and anger expression scale was used to find out the personal anger levels of each participant. The participants also clarified the persons and situations that made them angry at work. RESULTS: Trait anger levels were greater in the surgical residents in their first two years when compared with levels of their senior colleagues (p = 0.033). Mean trait anger levels were greater in the residents who were not satisfied with their department (p = 0.004). Anger levels were not found to be related to the number of shifts per month. Male residents had higher levels of anger than female colleagues (p = 0.019). CONCLUSION: Residents in clinical sciences seem to have the potential to benefit from a screening process in terms of anger and its subcomponents by means of a tool such as the trait anger and anger expression scale during their residency.

Snakebite during pregnancy.

Little is known about snakebites during pregnancy and only a few cases have been reported in the literature. The fact that venomous snakebites during pregnancy result in high fetal wastage and may cause maternal mortality makes this an important, albeit, uncommonly encountered entity in emergency medicine. In this paper, we report on the successful treatment of three cases of snakebite in pregnancy.

Intoxication with 100 grams of mercury: a case report and importance of supportive therapy.

Nearly everyone is at risk of acute and chronic toxic exposure to hazardous substances in the ambient environment. Morbidity and mortality following an overdose are reduced by intensive appropriate supportive therapy. A well-trained medical team is required for the administration of intensive clinical care, which includes enough equipment for monitoring the patient's status. In this paper we present a student who, after attending a dentist faculty, ingested 100 grams of pure inorganic mercury in order to commit suicide and was treated with forced diuresis, whole bowel irrigation, and D-penicillamine. The latter was found following 48 hours of therapy and only used for 4 days because of lack of availability of other antidotes for mercury in our city.

Cytodiagnosis of nipple discharge: a study of 602 samples from 484 cases.

To find out the gross and microscopic differentiating features between nipple discharges (ND) due to various breast lesions, smears of 602 ND samples from 484 cases were reviewed by one of the investigators (D.K.D.). The reviewed cytodiagnoses were as follows: benign nipple discharge (59.1%), inflammatory ND (6.5%), ?papillary lesions (2.5%), papillary lesions (20.6%), papillary lesions with atypia (3.8%), duct cells with atypia (0.2%), suspicious for malignancy (0.5%), malignant ND (1.2%), and inadequate (5.6%). Following review, samples with epithelial abnormalities (?papillary lesion, papillary lesion with and without atypia, duct cells with atypia, suspicious for malignancy, and malignancy) increased from 16.6% to 30.4% of adequate samples (P < 0.0001). 37.9% unilateral ND samples showed epithelial abnormalities, as opposed to 18.9% of bilateral ND samples (P < 0.0001). Bloodstained ND showed epithelial abnormalities in 41.5% samples, as compared to 22.1% of ND with other specified gross characteristics (P < 0.0001). The samples with epithelial abnormalities differed significantly from benign and inflammatory ND in respect of frequency of benign duct cells, duct cells with atypia, papillary clusters with or without atypia, malignant cells, columnar cells, red blood cells, inflammatory cells, and background lipid vacuoles (P < 0.01 to < 0.0001). The ND samples with suspicious and malignant cytology, besides the presence of malignant cells (P < 0.0001), differed significantly from rest of the lesions in respect of foam cells (P < 0.0001), red blood cells (P < 0.01), and inflammatory cells (P < 0.05). When compared with histopathological diagnosis in 20 cases, the benign or malignant nature of the lesion was correctly identified in ND in 80% cases. The ND cytologies in 7 histologically proved malignant cases were malignancy (3 cases), suspicious for malignancy (1 case), papillary lesion with atypia (1 case), papillary lesion (1 case), and benign ND (1 case).

A case of child abuse: haloperidol poisoning of a child caused by his mother.

This presentation focused on a hyperactive child admitted to the emergency department because of ataxia and imbalance. It was later discovered that the child had been abused by his mother. In cases where there is conflict between the clinical findings, the patient and the family's history in a clinical state which cannot be explained satisfactorily by the medical staff, the need for taking the history again from other relatives whilst taking into account the parents' physiological well-being, is time well spent.

Life-threatening uvular angioedema caused by Ecbalium elaterium.

Ecbalium elaterium, known as the wild or squirting cucumber, is a hairy perennial herbaceous vine of the Cucurbitaceae family, endemic to the Mediterranean region. All parts of the plant are toxic, particularly the gherkin-like fruits. It is frequently used in the treatment of sinusitis by nasal aspiration in some parts of the Mediterranean. The studies regarding to Ecbalium elaterium, argue that it has an anti-inflammatory characteristic. Two cases of uvular oedema have been ascribed to the undiluted use of this substance. Since they can threaten life, similar cases arising with the improper use of herbals should not be ignored in the emergency department. In this paper we present a life-threatening uvular angioedema caused by nasal aspiration of undiluted juice of squirting cucumber.

Sustained-release verapamil as a first-step drug in the treatment of mild to moderate hypertension.

The efficacy of sustained-release verapamil as a first-stage treatment for mild to moderate, uncomplicated essential hypertension was studied. Nineteen patients aged 36-70 years (mean +/- SD 55 +/- 10 years) entered the study. Treatment with 240 mg sustained-release verapamil, once daily for 8 weeks, caused systolic and diastolic blood pressures to decline significantly during the first 2 weeks and this lower level was maintained until week 8. Heart rate decreased gradually during the treatment period reaching significance at week 8. After 2 weeks maximum systolic and diastolic blood pressures during isometric exercise were significantly reduced compared with pre-treatment values; there was no difference in the percentage increase occurring pre- and post-treatment. These measures for heart rate did not change significantly. Except for a significant reduction in cardiac index after 8 weeks left ventricular function and left ventricular mass were unchanged. The 24-h urinary Na+ excretion increased significantly after 2 and 8 weeks' treatment. Plasma renin activity, serum lipid concentrations and routine blood chemistries were not affected. Side-effects were transient and did not require discontinuation of therapy. In conclusion, sustained-release verapamil is an efficacious and well tolerated first-stage drug in the treatment of essential hypertension.